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Teaching Series: Pathology Stage Clinic BP AMBP/HBPM Stage 1 >149/90 mmHg >135/85mmHg Hypertension Stage 2 >160/100mmHg >150/95mmHg Stage 3 >180/110 mmHg Epidemiology: Clinical Features: Management: - Affects 1/3 of people aged 45-54 yo - Asymptomatic - Lifestyle advice offered to all - Affects 70% of people over 70 yo - Symptoms related to secondary cause - Options: - As of 2015 it effected 1/5 adults in - Features of end organ damage A- ACEi/ARB England B- Beta Blocker C- Calcium Channel Blocker Investigations: D- Diuretic (thiazide like) 1. Take BP at clinic Aetiology: 2. ABPM/HBPM- if clinic BP is - <55yo OR Diabetic - Primary/essential (95%): There is no >140/90 1. A underlying cause 3. Additional investigations to check 2. A+C or A+D - Secondary (5%): 3. A+C+D for end organ damage: 4. K+ <4.5 = K+ sparing - Renal disease 1. Renal- U&E, creatinine, eGFR, diuretic; K+>4.5 = B - Other (obesity, anemia, renal ultrasound - >55 OR of Black African or Black aortic stenosis) 2. Cardio- Echo, ECG Caribbean descent - Pregnancy 3. Diabetes- Fasting blood glucose - Endocrine (Cushing, 4. Cholesterol- Lipid profile 1. C 5. Eyes- Fundoscopy 2. A+C or C+D phaeochromocytoma, 6. Additional inx for secondary cx. 3. A+C+D Conn Syndrome) 4. K+ <4.5 = K+ sparing diuretic; K+>4.5 = BStable Angina Definition/presentation: There are three INX: Epidemiology: - Men x2 more affected than features used -Primary care: ECG, Bloods, cons. Risk factors 1. Constriction/heavy discomfort to chest, - 1 line: CTCA indicated if a/typical angina pain or if women with radiation ECG shows ischemic changes in a chest pain with <2 - Prevalence in UK adults of 3% 2. Brought on by exertion angina features 3. Alleviated by rest (<5mins) or GTN nd - 2 Line: If CTCA inconclusive, stress echo, 3/3 features – Typical angina pain myocardial perfusion SPECT, cardiac MRI Risk Factors: 2/3 features- Atypical angina pain - 3 Line: If the above inconclusive, invasive coronary - DM, HTN, hyperlipidemia, 0-1/3 features- Non-anginal pain angiography smoking, obesity Management: Aetiology/Pathology: Classification: -Conservative: Manage risk factors Atherosclerosis narrows -Class I- No angina with normal activity; the arteries bring blood strenuous activity can cause symptoms - Medical Mnx: - Secondary prevention: ASPIRIN 75mg to the heart and the -Class II: Angina causes slight limitation on OD and STATIN 80mg ON atheroma reduces normal physical activity - GTN SPRAY vasodilator release. SO… -Class III: Angina causes marked limitation on - Anti-angina: 1 Line is BB or CCB; 2nd when O2 demand of the normal physical activity Line BB and long acting CCB; 3 Line BB heart increases, it -Class IV: Angina occurs with any physical cannot be met leading activity and may occur at rest and CCB and long acting nitrate - Revascularization: If not controlled by optimal to ischemia. medical management or complex three vessel diseaseAcute coronary syndrome (UA, MI) Epidemiology: Third Universal Definition of MI 2012 MNX: - 30% of deaths world wide A rise and/or fall in troponin with at least 1. MONAC: one value >99 percentile, evidence of -Morphine and Metoclopramide IV Aetiology: myocardia ischemia and at least one of the -Oxygen if SpO2<94% - Risks: DM, obesity, smoking, HTN, dyslipidemia, age, - Nitrate- GTN male sex, south Asian ethnicity, family Hx, previous MI following: - Atheroma ruptures, thrombus develops and causes - Symptoms of ischemia - Aspirin 300mg complete blockage of blood flow to the heart, leading to - ECG changes - Cardiac monitoring/glucose control ischemia. - Development of pathological Q waves 2. STEMI - Complete disruption to flow = STEMI - Imaging evidence of loss of viable -PCI if symptoms <12h of myocardium or regional wall abnormalities presenting to hospital and can be carried out - Incomplete disruption to flow = NSTEMI/UA in <2h - ID of intracoronary thrombus by Clinical Features: angiography -Thrombolysis if <12h but not able to have - Central crushing chest pain with radiation to the Features of STEMI on ECG: PCI within 2h neck/arm, occurs at rest and not relieved by 3.NSTEMI/UA rest/GTN. - ST elevation of >1mm in at least 2 -GRACE Score - SOB adjacent limb leads or >2mm in 2 -Low risk- FONDAPARINUX 2.5mg SC for 8 contiguous precordial leads or days - Sweating - New onset LBBB -Intermediate or high risk- IV glycoprotein - Nausea - Vomiting Complications of ACS : IIb/IIIa inhibitors and anticoagulation, Dresslers coronary angiography within 96h and PCI INX: Aneurysm 4. Post acute mnx: 1. ECG- recorded 15-30 mins apart Tamponade - Aspirin 75mg life long 2. CXR- assess cardio mediastinal features, Heart failure - P2-Y12 inhibitors for 12months lung fields and exclude non-cardiac Valve disease - Statin chest pain - Beta blocker Arrhythmia 3. Blood tests- Troponin T or I (serial- 6h Death - Nitrate apart), FBC, U&E, LFTS Embolism - ACEi -Cardiac RehabValve Disease Aortic Stenosis Aortic Regurgitation Mitral Stenosis Mitral Regurgitation - Narrowing of the mitral -Leaky mitral valve - Narrowing of the aortic valve -Leaky aortic valve valve -Acute Cx: Papillary muscle -Cx: Acute rheumatic fever, age -Acute Cx: IE, aortic dissection or -Cx: Acute rheumatic related degeneration, congenital chest trauma fever, age related infarct, ruptured chordae bicuspid valve, rheumatological -Chronic Cx: Rheumatic fever, degeneration, congenital tendineae, infective endocarditis, disorder, amyloidosis congenital valve deformity, trauma -Px: Syncope, angina, dysponea rheumatological arthritis, CT valve deformity, - Chronic Cx: Mitral valve rheumatological disorder, prolapse, ischemic, rheumatic -O/E: Slow rising and delayed disorders, DLE, syphilis amyloidosis heart disease pulse, narrow pulse pressure, -Px: SOB, pulmonary oedema, -Px: SOB, Fatigue, AF crescendo-decrescendo Hypotension -O/E: Tapping Apex beat, -Px: SOB, pulmonary oedema, murmurs -O/E: pulsus bisferiens, wide pulse loud S1, rumbling mid- Hypotension, cardiogenic shock, - INX: Echo, ECG CXR pressure, high pitched diastolic AF, left HF -Mnx: 1. Asymptomatic-followed murmur best heard on expiration, diastolic murmur, malar -O/E: Displaced apex beat, flush blowing apical pansystolic up; 2. AVR or TAVI collapsing pulse - INX: Echo, ECG CXR murmur -Indications for surgery: - INX: Echo, ECG, CXR cardiac cath -Mnx: asymptomatic severe AS, -Mnx: 1.Anticoagulation - INX: Echo, ECG CXR, cardiac cath asymptomatic and LVEF <50%, 1. HTN mnx 2. Symx: Diuretics and BB -Mnx: severe AS and undergoing other 2. Valve replacement 1. Anticoagulation cardiac surgery, very severe - Indications for surgery: 3. Valve intervention: 2. Symx: Diuretics PC Mitral balloon BB, ACEi asymptomatic AS, Asymptomatic Symptomatic severe AR, commissurotomy first 3. Valve intervention: severe and poor exercise asymptomatic severe AR with line replacement tolerance decreased LVEF, undergoing cardiac surgery for other reasonsArrhythmias-Bradycardia (<60bmp) Sinus bradycardia Heart block Bundle Branch Blocks -Normal rhythm, rate<60bpm First degree: Delayed or blockage in one of the bundle - Cx: Physiological, drugs (BB, CCBs, anti- -Delayed conduction so a prolonged PR interval arhythmics, digoxin), infiltrative disease, - Cx: Idiopathic, ischemia, physiological branches infective disease, metabolic disturbances, Right Bundle Block sick sinus syndrome - Px: Asymptomatic - Can be normal in some individuals - Px: Physiological is asymptomatic; - MNx: Not needed - Can also be a sign of RVH strain, pulmonary pathological cx fatigue, dizziness, syncope Second degree stenosis and emboli - INX: ECG and bloods -Mobitz type 1:Successive prolongation of the PR -MNX: - QRS looks like a M in V1 and a W in V6 1. Symptoms and HR- treatment depends until a beat is dropped on assessment and risk of asystole; any - Mobitz type 2:Intermittent dropped beats, Left Bundle Branch Block adverse signs, give atropine. normally every 2 or 3 beats - ALWAYS indicates pathology- IHD, 2. ATROPINE- 0.5mg IV, repeat up to 3mg - Treatment not needed unless symptoms are cardiomyopathy, LVH severe 3. No response to ATROPINE: ADRENALINE - Can be divided into anterior and posterior or temp pacing - Hemodynamic compromise treated with fascicular blocks; Bifasicular block RBBB 1. IV ATROPINE +LAFB/LPFB; Trifasicular block is bifasicular Sick sinus syndrome 2. ADRENALINE/ISOPRENALINE IV block + Prolonged PR interval - SAN dysfunction, encompasses sinus 3. Temporary pacing bradycardia, sinus pause and/or SA block - Cx: idiopathic fibrosis, infiltrative disease,rd degree Px: Chest pain (think MI) metabolic, ischemia, drugs - Complete HB i.e. there is no connection between Inx: Echo and coronary angiogram - Px: paroxysmal atria arrhythmias, dizziness,he P and QRS on ECG MNx: Trifasicular/bifasicular block- palpitations, syncope, chest pain - Cx: idiopathic, anterior MI permanent pacemaker - Mnx: Treat the cause; IV ATROPINE and temp - Px: Low cardiac output, dizziness, syncope, SOB, pacing; NICE recommends dual chamber pacemaker for all symptomatic patients stokes Adams, cannon A waves - MNX: Permanent pacemakerArrhythmias- Narrow complex tachycardia (HR>100bpm, QRS<0,12s) Narrow complex: Sinus Tachycardia Narrow Complex: Atrial Fibrillation - HR>100bpm - AF is an irregularly irregular pulse - Can be physiological or pathology - Acute: <48H - MNx: Treat the underlying cause. BB used in the majority; radiofrequency - Paroxysmal: <7 days, self-limiting episodes ablation in cases refractory to medical therapy - Persistent: >7 days, not self limiting, can become permanent - Permanent: Over a year, resistant to treatment Narrow complex: Atrial Flutter - Regular rapid atrial - Cx: ischemic heart disease, right atrial dilation, certain medications - Cx: Alcohol and caffeine, thyrotoxicosis, rheumatic fever and mitral valve pathology, ischemia heart disease, atrial myxoma, lungs, electrolyte disturbances, pharmacological, - Px: Sawtooth on ECG iatrogenic, blood pressure, infections - Inx and Mnx like AF Narrow Complex: SVT -Px: asymptomatic, SOB, palpitations, syncope/dizziness, chest discomfort, stroke/TIA - Tachycardia not of ventricular origin - Re-entry tachy: AVNRT, AVRT -Inx: ECG -> Bloods -> Echo -> Assessment of need/risk of anticoagulation - Automatic tachy: Junctional, atrial - Px: palpitations, dizziness, SOB, chest discomfort, low BP, syncope Acute Mnx: - Inx: ECG-> Bloods -Hemodynamically unstable: Synchronized DC cardioversion +/- AMIODARONE -Stable and <48h: LMWH + electrical/pharmacological cardioversion -Mnx: - Stable and >48h: 3-week anticoagulation + DC cardioversion 1. Hemodynamically unstable- Sedation and urgent DC Cardioversion 2. Hemodynamically stable- Vagal Manoeuvres Chronic Mnx: 3. ADENOSINE: 6mg->12mg->12mg - Rate control first line unless there is a reversible cause, new onset AF, HF is present, or (VERAPAMIL if ADENOSINE contra; DIGOXIN/AMIODARONE/BB used if rhythm control is more appropriate. BB/CCB first line, then combo of unsuccessful; DC cardioversion if medication not successful) BB/diltiazem/digoxin - Rhythm control if the above criteria apply, or if patient has heart failure or is younger. 4. Radiofrequency ablation Electrical or pharmacological cardioversion can be used (AMIODARONE, FLEICANIDE, Narrow Complex: Wolff-Parkinson White SOTALOL) -Results from an accessory pathway known as the bundle of kent. - Anticoagulation: Assess need using CHA2DS2VAS and HAS-BLED score; WARFARIN or -Look for delta waves on ECG; Mnx with catheter alation of accessory NOAC pathwayArrhythmias- Broad complex Tachycardia (>100bpm, QRS>012s) Ventricular tachycardia Brugada syndrome Ventricular fibrillation - Tachy originating from the - Autosomal sodium channelopathy - Rapid, uncoordinated life-threatening ventricular ventricle associated with sudden cardiac arrhythmia that results in hemodynamic collapse - 3+ successive broad QRS with a death - If untreated it is life threatening rate >100bpm - Px: Shorter AP, down sloping ST - Cx: Ischemic Heart disease, electrolyte abnormalities, - Most common cause of sudden elevation followed by inverted T structural heart disease cardiac death wave in V1 and V2 , syncope, sudden - PPx: micro re-entrant circuits forming within the - Cx: Ischemia, structural heart cardia arrest ventricles disease, electrolyte abnormality, -Mnx: ICD implant is the only - Mnx: ALS medications definitive treatment -Px: Asymptomatic, palpitations, dizziness, hemodynamic instability Extra beats (hypotensive, tachy, SOB, Long QT-syndrome -Premature atrial ectopics originate from an atrial dizziness, cardiac arrest) - A group of inherited/acquired conditions -Mnx: thar cause prolongation of QTc (calculated ectopic focus withing the atria. More common in 1. If hemodynamically unstable: using Bazett’s formula those with elevated atrial pressures. Usually benign, - Cx: Inherited mutations (LQT1-LQT13), but those who experience symptoms are given Synchronized DC shock and IV BB/CCBs. amiodarone; ICD considered Electrolyte abnormalities (hypocalcemia, - Premature ventricular ectopics refer to beats once stable hypokalemia, hypomagnesaemia), drugs originating from an ectopic focus in the ventricles. 2. If hemodynamically stable: IV (erythromycin, tricyclics, methadone, AMIODARONE or IV amiodarone), hypothermia They are found more often in older people and in - Px: syncope, sudden death, seizures those with ischemic heart disease. They are usually LIDOCAINE, Overdrive pacing, - Increased risk of torsades de pointes benign but can cause palpitations. DC cardioversion -Any recurrent ectopics should be investigated - Mnx: Avoid causative drugs and ICD if neededHeart failure INX: Anatomical 1. Bloods LHF- Backup into lungs; IHRHF 2. BNP- BNP >100pg/ml investigate within 6 weeks; BNP>400pg/ml valvular disease, investigate within 2 weeks cardiomyopathy 3. CXR: Alveolar oedema, Kerley B lines, Cardiomegaly, upper lobe Functional diversion, pleural effusion Systolic- HFrEF; IHD, MI Diastolic- HFpEF; restrictive Echo cardiomyopathy/pericarditis5. ECG 6. Other- angiography, CT scanning and cardiac MRI Low output- pump failure; High output- Inability of IHD, Aortic stenosis; coolheart to meet metabolic MNX: peripheries demands; thyrotoxicosis, AV1. Lifestyle modifications- smoking cessation, fluid and salt fistula, B1 def, pregnancy and restriction, restrict alcohol, optimize diet and exercise severe anemia; warm peripheries 2. Diuretics- Loop (FUROSEMIDE); symptom management 3. ACEi- Improve mortality and morbidity Temporal 4. Beta blockers- Improve mortality and morbidity Acute- Medical emergency Chronic 5. Mineralocorticoid receptor antagonists- Improve mortality Px: Dyspnea, orthopnea, PND, cough, chest 6. Ivabradine discomfort, peripheral oedema, fatigue 7. Hydralazine and nitrate 8. Device therapy and surgery: CRT-P indicated in severe HF with LVEF O/E RHF: elevated JVP, hepatomegaly, ascites, peripheral oedema <35% and broad QRS complex; ICD indicated in previous VF/VT and O/E LHF: Displaced apex beat, S3, Pulmonary reduced ejection fraction; LVAD used as a bridge to transplant; congestion Cardiac transplant, in younger patientsMCQsQuestion 1. • A patient presents with crushing central crushing chest pain that started 8 hours ago. The pain came on at rest and was not relieved by rest/GTN. ECG shows an STEMI. What is the initial treatment for this patient? • A. Thrombolysis • B. Calculate a GRACE score • C. Morphine, oxygen, nitrate, aspirin, cardiac monitoring • D. PCIQuestion 1. • A patient presents with crushing central crushing chest pain that started 8 hours ago. The pain came on at rest and was not relieved by rest/GTN. ECG shows an STEMI. What is the initial treatment for this patient? • A. Thrombolysis • B. Calculate a GRACE score • C. Morphine, oxygen, nitrate, aspirin, cardiac monitoring • D. PCIQuestion 2 • A patient comes to the ED due to palpitations and feeling generally unwell. The palpitations are new and an ECG shows Atrial fibrillation. As part of your ABCDE assessment you check their BP which is 90/50. What is your initial management? • A. Reassure and discharge • B. Start anticoagulation and cardiovert in 3 weeks • C. Chemical cardioversion • D. Synchronized DCQuestion 2 • A patient comes to the ED due to palpitations and feeling generally unwell. The palpitations are new and an ECG shows Atrial fibrillation. As part of your ABCDE assessment you check their BP which is 90/50. What is your initial management? • A. Reassure and discharge • B. Start anticoagulation and cardiovert in 3 weeks • C. Chemical cardioversion • D. Synchronized DCQuestion 3. • You are in an OSCE and you are asked to listen to a murmur. You hear an ejection systolic murmur with radiation to the carotids. What other feature would you expect on examination? • A. Narrow pulse pressure • B. Wide pulse pressure • C. Malar flush • D. Displaced apex beatQuestion 3. • You are in an OSCE and you are asked to listen to a murmur. You hear an ejection systolic murmur with radiation to the carotids. What other feature would you expect on examination? • A. Narrow pulse pressure • B. Wide pulse pressure • C. Malar flush • D. Displaced apex beatSources • Medicine in a Minute • Quesmed- quesbook • Zero to FinalsPericarditis Definition: INX: Constructive Pericarditis Inflammation of the pericardium 1. ECG- Wide spread ST - Progressive thickening, elevation, PR segment fibrosis and calcification Aetiology/PPx: depression of the pericardium - Idiopathic or viral (coxsackie, echovirus, -Cx: TB, mediastinal EBV) 2. Bloods- elevated WBC, CRP irradiation, cardiac -Autoimmune disease and Troponin -Acute MI 3. CXR and Echo- Pericardial surgery, tissue disease effusion -Px: Heart failure, low -Dressler’s syndrome cardiac output, dyspnea - Drugs: HYDRALAZINE, ISONIAZID, MNX: on exertion and fatigue PROCAINAMIDE, PENICILLIN 1. NSAIDs/ASPIRIN - Inx as before- CXR - Uremia 2. COLCHICINE to prevent shows pericardial recurrence calcification and echo Px: 3. CORTICORSTEROIDS in CT -Sharp retrosternal or left sided chest shows restrictive mitral pain disease, uremic or immune filling pattern and - Pain worse on leaning back and mediated pericarditis pericardial thickening better leaning - Medical therapy: Diuretics, NSAIDs, - Viral Prodrome steroids and colchicine - Pericardiectomy is the only definitive mnx Modified Dukes Criteria: Major criteria- Infective Endocarditis -Blood cultures: - Two+ separate blood cultures demonstrating PX: typical organisms Definition: - Fever -Two +ive Cultures >12h apart or three +ive cultures - Embolic phenomena or a majority of >4 +ive cultures >1 hour apart Infection of the endocardium and all its - New or changing murmur - Serology: Single +ive blood culture for c.burnetiid related structures - Textbook: Roth spots, splinter or an antiphase 1 IhH antibody titer pf>1/800 hemorrhages, Osler nodes, - Echo: Epidemiology - Males predominantly Janeway lesions -+ive echo demonstrating oscillating mass, abscess or dehiscence of prosthetic valve - Complication of rheumatic heart INX: - New valve regurgitation disease 1. Blood cultures- 3 sets, Minor criteria - Most commonly in older patients and 12h apart -Positive blood culture/echo IVDU 2. Echo- TTE first line, then - Vascular phenomenon TOE; shows oscillating - Predisposing heart disease Aetiology: - Infective cx: staph aureus, strep viridans, irregular - Fever >38 HACEK group mass/vegetation - Immunological phenomena 3. Other- Bloods, - Tests - Non-infective Cx: SLE, Autoimmune, urinalysis, CXR and ECG, 2 Major criteria or 1 major and 3 minor or 5 minor malignancy dental evaluation - Risks: Increased age, being male, dental MNX: procedures, IVDU, structural HD, prosthetic 1. IV AB: VANCOMYCIN/FLUCLOXACILIN with GENT 4-6/52 (Native); VACY+GENT+RIFAMPICIN heart valves, immunodeficiency 6/52 2. Surgery: Consider in acute MR or AR with HF, persistent bacteremia or valve dysfunction, fungal endocarditis, prosthetic valve endocarditis, recurrent emboli, annular abscessCardiomyopathy Dilated cardiomyopathy Hypertrophic cardiomyopathy Restrictive cardiomyopathy - Characterized by dilation and systolic - Autosomal dominant - Contraction against stiff, non-dilated dysfunction of the left and right ventricle - Asymmetrical left ventricular ventricle with near normal systolic -Aetiology: Chronic alcohol consumption, function genetic, viral infections, hypothyroidism, hypertrophy and diastolic - PPx: Fibrosis or accumulation of peripartum cardiomyopathy, chemotherapy dysfunction substances in the myocardium, - Px: Asymptomatic, angina, SOB, -Px: Heart failure, SOB, thromboembolism or syncope, sudden death amyloidosis, systemic diseases pts may be asymptomatic - Inx: Echo, endomyocardial biopsy, CT, -Investigations: Echo is gold standard - Inx: Echo- thickened IV septum MRI and diagnostic angiography - Mnx: Mnx of heart failure, anticoagulation, - Mnx: -Mnx: Treat the underlying cause, ICD or CRT 1. Manage LVOT and SAM- avoid anticoagulation, treatment of heart failure volume depletion; BB or rate Takotsubo cardiomyopathy - Broken heart syndrome limiting CCBs; surgical Arrhythmogenic right ventricular - Thought to be a catecholamine myectomy, alcohol septal cardiomyopathy mediated response to severe stress ablation, diuretics, heart - Cardiomyopathy that presents with transplant arrhythmia or sudden death events 2. Prevent sudden cardiac death- - Px: Mimic MI, apical ballooning of the -PPx: Genetic mutations in the left ventricle ICD desmosomes lead to fibro-fatty infiltration - Self limiting but there is a rsik of 3. Offer screening to first degree of the myocardium sudden cardiac death due to relatives -Inx: ECG, Echo, Notching of QRS complex arrhythmia or ventricular free wall (epsilon wave and T wave inversion) rupture - Mnx: symptom mnx and ICD -Mnx: Monitoring, BB, ACEi